Failure to Reposition Bedbound Resident with Pressure Ulcers Every Two Hours
Penalty
Summary
A deficiency was identified when a resident with multiple pressure ulcers, including Stage III and Stage IV wounds, was not repositioned every two hours as required by their care plan and facility policy. The resident, who was in a persistent vegetative state and fully dependent on staff for all activities of daily living, was observed lying on her left side for over three and a half hours without being repositioned. Multiple staff interviews confirmed that the resident should have been turned at least every two hours to prevent further skin breakdown and to comply with the care plan interventions. The resident's medical history included acute and chronic respiratory failure, non-traumatic subarachnoid hemorrhage, COPD, ventilator dependence, and persistent vegetative state. The care plan specifically addressed the need for frequent repositioning due to the presence of pressure ulcers on several body sites, and the use of a low air loss therapy mattress was ordered for wound management. Despite these interventions, direct observations and staff interviews revealed that the resident was not repositioned as required, and staff acknowledged the lapse in care. Facility policies on prevention of pressure injuries and repositioning outlined the necessity of individualized repositioning schedules, with a minimum standard of every two hours for bed-bound residents. The Director of Nursing and other staff verified that the resident had not been repositioned according to the care plan, and that simply placing a pillow under the resident did not constitute a proper repositioning. The failure to follow the established care plan and facility policy resulted in the identified deficiency.